1. “Introducing Lean to the Hospital”
Peter D. Schellinck
Partner
SHConseil
+32 496 386 437
www.shconseil.fr
www.schellter.eu

2. Agenda
 The Crisis of Waste in Healthcare
 Lean Thinking Principles in Healthcare
 Benefits for:
 Patients
 Employees
 Hospitals

3. Hospitals Are Dangerous…
CDC 1998:
90,000 killed
and 2,000,000
injured from
hospital-caused
drug errors &
infections

4. Preventable Errors Abound…
“… 3 to 5% of
specimens taken
each year are
defective… blood
that isn’t drawn
correctly… mix-up
with another
patient’s sample”

5. Preventable Errors Abound…

6. Preventable Errors Abound…

7. Mass Production or Healthcare?
 Large batches  Automation is the answer
 Sub-optimizing one  Lack of standard processes
resource
 Lack of employee input  Not communicating
metrics
 One-person/One-machine  Lack of leadership
 Quality through inspection  Constant fire fighting

8. Non-Lean, Current Thinking
1. Specify value in the eyes of the
provider (or the payer)
1. Identify your department and
sub-optimize it
1. Make patients wait for the
convenience of the system
1. Ignore some employees and
devalue others
1. Continuously fight the same fires
in the pursuit of surviving the day

9. Applications of Lean in Healthcare
 Laboratories
 Reducing Turn Around Times and Errors
 Emergency Departments
 Reducing diversions, improving flow
 Outpatient Cancer Treatment
 Reducing patient delays, increasing capacity
 Operating Rooms
 Reducing changeover times, increasing utilization
 Pharmacies
 Reducing errors, improving response
 Food Service
 Reducing wasted food, improving quality

10. Why LEAN Works in Healthcare
 LEAN is not a list of tools that applies only
to factories
 LEAN is a philosophy of management that
applies to any system
 LEAN rallies people around goals we can all
agree on:
 Patients and Employees
for
Quality

11. Not About Cutting Heads
 Shortages of skilled employees
 51% of hospital med techs greater than 45
years of age, vacancy rate at 11%
 Shortfall of 65,000 nurses expected by 2012
 Do more…
 With the same
 Eventually, with less

12. Not Only About Cutting Costs
 Hospitals are using lean as a
Business Strategy
 Improving quality
 Improving service
 Improving employee satisfaction
 Growth strategies
 “Un-outsourcing” testing work

13. Principles of LEAN Thinking
1. Specify value in the
eyes of the customer.
– The customer must be willing
to pay for the activity
– The activity must change the
form, fit or function of the
product or service
– The activity must be done right
the first time
Who are the “customers?”
Source: LEAN Thinking, Womack and Jones 1996

14. Principles of LEAN Thinking
1. Specify value in the
eyes of the
customer.
2. Identify the value
stream and
eliminate waste.
13% of hospital costs are due to controllable
waste.
Source: Zuckerman, Hadley, and Iezzoni, 1994

15. Treatment Center
Typical Organization is Silo-ed
Treatment Clinic Check-In
Pharmacy
Laboratory Testing
Phlebotomy
Physician Clinic

16. Value Stream – Anatomic Pathology
Patient & MD I
Transcriptionist I
Pathologist
Specimen I
Collection
Send to
Grossing
I
Embed Slide
I Grossing Processing
& Cut
Staining
Making
I I I I

17. Types of Waste – Lab Examples
 Defects  Label on the wrong tube
 Overproduction  Drawing all blood at 4 AM
 Transportation  Long walks, multiple handoffs
 Waiting Time  Tube waiting on centrifuge to fill
 Inventory  50 weeks of supply
 Motion  Tech walking 80 ft to the printer
 Processing  Time/Date stamps added, not used
 Human Potential  Administration not listening to Med
Techs or ideas for improvement

18. Are We Tolerating Waste?
 Healthcare = Workarounds
 Professor Steven Spear
 “Decoding the DNA of the Toyota Production
System” (HBR)
 “Fixing Healthcare Today From the Inside” (HBR)
 Case Example:
 10-20% of MD orders are missing EVERY DAY
 Call and get the order – done?
 Tomorrow, we’ll do the same
 Problems need to be seen as opportunities

19. Laboratory Layouts Drive Waste
Layout is driven by
departments
Benches interfere with
straight-line walking,
encourage batches

20. Clinical Laboratory Product Flow

21. Clinical Laboratory Timeline
Total CT = 5.44 hours

22. Layouts Drive Waste of Motion
Med Tech Walk Pattern Pharmacist Walk Pattern
Kms per Day!
Cancer RN Walk Pattern

23. Typical 5S Baseline
 Unorganized Workbenches  Poor Utilization of Space
 Product Flow not Obvious  General Clutter
 Time wasted looking for things  Supply Shortages and
 Hoarding of supplies “Hidden” Inventories

24. 5S Improvement Examples

25. Principles of LEAN Thinking
1. Specify value in the
eyes of the customer.
2. Identify the value
stream and eliminate
waste.
3. Make value flow at
the pull of the
customer.

26. Reducing Patient Wait Times
 Mass Production Thinking Utilization
 Keep expensive assets heavily utilized
 Machines Doctors
 The tradeoff is waiting time
 Cars Patients
 Lean Thinking Flow
 Focus on reducing Patient Waiting time

27. Outpatient Oncology Patient “Flow”
Value Added
A
• Blood drawn
• MD consult
• Needle into Port
NVA But Required
B
• Check In / Check Out
• Moving from room to room
ARRIVAL TO LATENESS FOR NVA, “Pure Waste”
TREATMENT TREATMENT
PATIENT (HOURS) (HOURS) • Waiting for Check In
A 2,5 0,42 • Waiting for MD
B 3,5 1,08 • Waiting for Treatment
AVG 3,0 0,75

28. Re-Work Loops Cause Delays

29. Batching Prevents Flow

30. Batching Hurts Quality
 Lack of “standard work” and opportunity
for “error proofing” – Anatomic Pathology
Batch of slides made, 3 2nd histotech labels one
patients, risk of mixup? slide at a time

31. Batching Hurts Quality
 Lack of “standard work” and opportunity for
“error proofing” – Pharmacy

32. Flow
 You can’t have flow without some
amount of “leveling” in the system
 “Leveled Production:
 You won’t be Happy without it”
 From Toyota publication

33. Typical Hospital Lab  Not Level
39% of Samples Arrive in Just 3 Hours of the Day
TAT expectations are constant

34. Leveling Reduces Peak Costs
Shift Shift Shift

35. Principles of LEAN Thinking
1. Specify value in the eyes of
the customer.
2. Identify the value stream and
eliminate waste.
3. Make value flow at the pull of
the customer.
4. Involve and Empower
employees.
5. Continuously improve in the
pursuit of perfection.

36. Pre-Lean Med Tech Quote:
“With all of the
automation,
I feel like a robot.”

37. The “Thinking Production System”
“Perhaps the greatest strength of the
Toyota Production System is the way
it develops people.
This is why the T actually stands for
‘Thinking’ as well as for ‘Toyota.’”
 Teruyuki Minoura, Toyota

38. What Mistake-Proofing Means to
Healthcare
The Global Goal: Reduce Medical Errors
“Human error is inevitable.
We can never eliminate it.” …..
We can eliminate problems in the
system that make it more likely to
happen.”
Source: USA Today Liam Donaldson
August 24, 2005 WHO World Health Alliance
for Patient safety

39. Lean Requires a Cultural Shift
 Traditional Approach:
 “Naming, Shaming, and Blaming”
 Lean Approach:
 Supports open reporting of mistakes
 Root cause problem solving process
 “Anyone can make mistakes”

40. Error Proofing Example
 Micrograms or Milligrams?
 A medical mistake waiting to
happen when written by hand

41. Error Proofing Example
Confusing
Unambiguous
(Lean)

42. MD Resistance to Standard Work
Which is
More effective?
 “… some surgeons make a tiny, mole-sized mark on a
patient instead of a big, bold "X”…. I call them passive-
aggressive marks…”
 USA Today, 4/18/06

43. Lab Benefits from Lean
 Productivity improvement >30%
 Space savings of >250 sq m
 Standardized work practices
 Reduction in Errors and Error Potential
 Test Turnaround Time (CT) reduced by 50%

44. Reflections on Year’s in Healthcare
 Lean is a powerful methodology
 People are people
 Healthcare people have incredible intrinsic
motivation
 Humility and asking questions is better
than being a know-it-all
 Coaching the team to “do lean & be lean”
is the only sustainable route